Oral cancer, a leading cancer-site in India, is often detected at advanced stages. We evaluated the time intervals from first symptom to help-seeking and diagnosis among oral cancer patients.
In this cross-sectional study, we recruited 226 consecutive oral cancer patients (mean age ( ± SD) 51.9 years ( ± 10.9); 81.9% men; 70.3% advanced stage) registered for diagnosis and treatment, between 2019 and 2021 at a cancer care centre in South India. We used WHO framework and previously standardized tools to record time intervals (appraisal, help-seeking and diagnostic) and baseline characteristics. We utilized multivariable logistic regression models to test the associations between ‘prolonged (i.e., over 1 month) time intervals’) and patient-level factors to estimate odds ratios (ORs) with 95% confidence intervals (CIs).
Over a half of patients presented with prolonged appraisal (60%) and help-seeking intervals (57%), and a third (34%) reported prolonged diagnostic interval. Patients with no formal education, no routine healthcare visits, no self-reported risk factors, and those who did not perceive initial symptoms to be serious were 2–4 times more likely to have prolonged appraisal and help-seeking than the rest. High travel costs and self-decision for visiting healthcare facility prolonged help-seeking. Diagnostic interval was prolonged only among women OR= 2.7 (95% CI: 1.2–6.1)) and in patients whose first doctor’s opinion was ‘nothing to worry’ OR (=7.3 (95% CI: 2.6–20.5)). ‘Correct knowledge of cancer’ shortened appraisal and help-seeking intervals and ‘incorrect knowledge and negative beliefs’ prolonged diagnostic interval.
Our findings highlight that interventions targeting sociocultural and economic determinants, symptom awareness, sensitizing persons at risk (especially women) and primary care providers might reduce overall time to diagnosis. Further, patients without any known risk factors for oral cancer might be at-risk for prolonged appraisal interval. These might help inform ‘pull’ strategies for cancer control in India and similar settings.
- • Evaluation of the time intervals from first symptom to help-seeking and diagnosis among oral cancer patients.
- • Inequitable access to cancer care at the health system level (‘push’ strategy)
- • The ‘pull’ strategy involves psychological (fear, beliefs & stigma) and knowledge factors.
- • Appraisal, Help seeking and Diagnostic Time Intervals using WHO framework and previously standardized tools
More than half of all cancers (59%) and two-thirds of worldwide cancer deaths (71%) were estimated to occur in low- and middle-income countries (LMICs) in 2020 . Cancer patients who live in LMIC are more likely to experience delays in diagnosis and care compared to their counterparts residing high-income countries. This is attributable to the lack of equitable health services and inadequate cancer literacy . According to World Health Organization (WHO) in 2015, over 90% of cancer patients in high income countries, but only about 50% of patients in LMICs, had access to public sector treatment facilities .
India is the third highest contributor of overall cancer burden worldwide and the leading contributor of new cases and deaths in LMICs . Three out of four cancer patients in India’s public sector experience limited or delayed treatment . While inequitable access to cancer care need to be addressed at the health system level (‘push’ strategy), delays in seeking help represent a critical intervention target at the patient level (‘pull’ strategy) . The ‘pull’ strategy involves addressing individuals’ psychological (fear, beliefs & stigma) and knowledge factors, as well as the larger network of socio-cultural, and economic barriers . Studying these factors comprehensively is essential for relevant cancer control measures.
According to the WHO recommendations the period from symptom onset to initiation of treatment should not exceed 90 days. As recently reviewed elsewhere health literacy, stigma, access to primary care, financial, socio-cultural, and regional aspects are the commonly reported barriers at the patient-level in LMIC settings. Importantly, less than half of the studies included in the review conformed to the WHO framework or utilized standardized tools for assessment; the data from India deemed especially limited and unstructured.
Oral cancer is a leading malignancy among men and women in India. Despite offering a relatively easy target for early detection, oral cancers are often diagnosed at advanced stages . This may partly be due to yet unidentified barriers at patient-level. This cross-sectional study conducted among oral cancer patients in a tertiary cancer centre in India, sought to address these gaps in knowledge by investigating three time-intervals: appraisal, help-seeking and diagnostic. Each interval was ascertained based on WHO framework using previously standardized tools intended for LMIC settings . In the present analysis we considered a wide range of demographic, socio-economic, lifestyle and cultural, and disease-related factors as well as factors related to healthcare access and diagnosis hypothesized to be associated with prolonged time intervals.